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Coordinated planning of a patient's care
following a hospital or nursing home stay can greatly affect health
outcomes, likelihood of readmission and/or emergency room visits, as
well as cost to patients, providers and insurers. A discharge
management plan that integrates community resources and programs can
further ease the transition from hospital to home and improve
continuity of care.
Discharge
Planning Primer: Community Collaborations to Decrease Hospital
Readmissions Risk profiles two aptly named discharge
management efforts that access and maximize partner resources for their
populations. CHOICES is a hospital-based case management program for
older adults in Albany, N.Y., while CASA (Community Alternative Systems
Agency) in Broome County, N.Y. is a community-based initiative that
collaborates with hospitals and nursing homes to help frail elders and
young disabled adults. Both are client-centered models in discharge
planning designed to meet the physical and psycho-social needs of their
respective populations.
In
this 32-page special report, "Discharge Planning Primer: Community
Collaborations to Decrease Hospital Readmissions Risk," Nora
Baratto, manager of the case management department at St.
Peter's Hospital's CHOICES program, and Michelle M. Berry,
CASA director, describe the coordinated approaches central to their
hospital discharge processes and the impact their programs have had on
patients' outcomes and satisfaction, hospital readmission rates and
healthcare costs. The CHOICES program has been so well-received that
St. Peter’s Hospital now makes it available to its own
employees as an elder care benefit.
And
with readmission rates affecting quality and profitability, the
healthcare industry is taking notice. In this special report, you'll
also get a summary of more than 200 responses to a non-scientific
e-survey conducted in 2007 by the Healthcare Intelligence Network on
how healthcare organizations are working to reduce hospital
readmissions.
Ms.
Baratto and Ms. Berry share details on the comprehensive assessments,
home visits, transition planning, and collaborative partnerships that
are integral to their discharge management processes. They provide
details on:
- Overcoming barriers between the health system
and community;
- Successfully transitioning patients from one
care setting to another;
- Identifying patients at risk for readmission;
- Forging collaborations with emergency room
staff, inpatient staff, community physicians, and community agencies
during discharge planning;
- Educating clients, family and caregivers on
care access and appropriate use of health resources;
- Developing a home visit checklist for
comprehensive assessments of patient condition;
- Benefits gained and lessons learned in the
discharge planning process;
- and much more.
PLUS,
this report contains:
- Details on new practices in hospital discharge
instructions and in-person, print and telephonic initiatives underway
industry-wide to pare hospital readmission rates;
- 14 pages of Q&A that offer practical
strategies for coping with non-compliant patients, culturally diverse
populations and breakdowns in the discharge process.
This
report is based on a 2007 audio conference on best practices in
hospital discharges to reduce preventable readmissions.
Table
of Contents
- St. Peter’s CHOICES Program Breaks
Down Barriers to Care
- CHOICES Provides Collaborative Approach
- Services Provided by CHOICES
- Significant Referral Sources
- CHOICES Program Outcomes
- Broome County CASA: Discharge Planning via
Community Collaboration
- The Importance of Community Collaboration
- Getting the Frail and Disabled Home
- Lessons Learned in Discharge Planning
- 2007 HIN Survey Results: How Health Plans and
Hospitals Are Preventing Readmissions
- Q&A: Ask the Experts
- Case Managers as Educators
- CHOICES Program Outcomes
- Data Supports the CHOICES Program
- Addressing Breakdowns in the Discharge Process
- Education & Effective Questioning
Reduces Readmissions
- Walking Through a Home Visit
- Physician Feedback on Program Extremely
Positive
- Home Visits by Practitioners
- Handling Young Disabled Adults
- Discontinuing Care for Non-Compliant Behavior
- Measuring Outcomes & Utilizing Trend
Data
- Community Partnering Critical
- Meeting the Needs of Immigrants & the
Homeless
- Translators for Cultural Issues
- Helping the Homeless Access Medicaid
- A Guest Book for the Homebound
- Working with Managed Care
- Reviewing Cases to Avoid Readmissions
- Glossary
- For More
Information
- About the Authors
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